GW1-2022-07476_Well Construction - GW1_20220810

` RESIDENTfAL WELL.CONSTRUCTION RECORD
- ff North Carolina Department of Environment and Natural Resources.Division of Water Quality
01-11 /' � _ 1 1
WELL CONTRACTOR CERTIFICATION# (�
1.WELL CONTRACTOR: g. WATER ZONES(depth
TONY R DAVIS Topy�Bottom Top Bottom
Well Contractor(Individual)Name Top Bottom Top Bottom
DAVIS WELL BORING Top Bottom Top Bottom
Wall Contractor Company Name
Thicknessf
1481 LARRY DAVIS ROAD 7. CASs G• Depth Diameter Weight Material
Street Address Top Bottomy/ Ft. ,24 1.5 Cement
LAWNDALE NC 28090 Top Bottom Ft. 1 _
City or Town State Zip Code Top�T Bottom Ft._
( 704 276-3434
Area code Phone number. 8. GROUT: Depth Material Method
2.WELL INFORMATION: 02, 7 Top 0 Bottom 20 Ft. Concrete Truck
WELL CONSTRUCTION PERMIT# M(Q�Z �/i42X Top Bottom Ft
OTHER ASSOCIATED PERMIT#(trapplicable) TOP Bottom Ft
SITE WELL ID#(f appGcable) 9. SCREEN: Depth Diameter Slot Size Material
3.WELL USE(Check Applicable Box): Residential Water Supply 111110400— ; Top Bottom Ft_ .In. in.
DATE DRILLED ' Top Bottom Ft `In. in.
TIME COMPLETED AM ElPt��
Top Bottom Ft in. in.
a.WELL LO ATIPIk4 10,SANDIM- VEL PACK:`
�J 0epthr. 81ze Material
CITY; GOON per: Top Bottom-4-VFt j8—M Gravel
d C, Top Bottom Ft
t treat Name,Numbers,Commwity,Subdivision,Lot No.,Parcel,Zip Code) Top Bottom Ft
TOPOGRAPHIC/LANDS ING: ;cheat appropriate box}
[]Slope O Valley S13t�p Ridge 0 Other , 11. DRILLING LOG
LATITUDE �t DMS OR 3X.XXXXXXXX'X DD Top Bottom Formation Description
LONGITUDE. ° "DMS OR 7X7*D=xyxx DD /
Latltude/Iongitude source: BPS At ep6graphic map J
(Iocallon of well m&st be shown on a USGS topo map andatfeched to /
this form ff not uslog GPS) J
S.W LL O NER /
O V
Owner Name -
sd
S t Add7s J y, fc
City or Town State Zip Code
Area code Phone number
12. REMARKS:
S.WELL DETAILS:
a. TOTAL DEPTH: ,
b. DOES WELL REPLACE EXISTING WELL? YES�/lC�D
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: F1`. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'if Above op of Casing) STANDARDS,AND THAT A COPY GAF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER;
d. TOP OF CASING IS ` FT,Above Land Surface•
'Top of casing terminated atlor below land surface may require �r /y1I/
a variance in accordance with 15A NCAO 20.0t1t3. : SIG ATURE—O ,IFIIFI—ED WELL CONTRACTOR DATE
e. YIELD(gpm): E1Ta0D F TEST TONY R DAVIS
f. DISINFECTION:Type �14mount PRINTED NAME OF PERSON CONSTRUCTING THE vvELL
Submit within 36 days of completion to: ivision Of Water Quality- information Processing, �� �W_ia
1617 Mail Service Center, Raleigh, NC 27S99-161, Phone : [phone] Rev.2109

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